23-751m Reminder About Timely Response to Enrollee Appeals and Grievances

Date: 07/31/23

Review enrollees' rights, response time frames for information requests and other requirements 

Enrollees have the right to file a concern about the care and services they receive from Health Net, its participating physician groups (PPGs), physicians and other providers.

Appeals or Grievances submitted on behalf of an enrollee must include an Authorization for Representation Form containing the enrollee’s signature and consent.

When to submit an enrollee appeal or grievance

California regulations require health plans to allow submission of an appeal or grievance within the applicable regulatory timeframes. Enrollees need to include all information from their medical identification card and the details of the concern or problem.

Receipt of an appeal or grievance

Health Net must acknowledge an enrollee’s appeal or grievance within 5 calendar days for commercial plans (HMO, POS, HSP, EPO, and PPO) and 5 working days for Medi-Cal from the receipt date of the request. The receipt date of an appeal or grievance is the earliest stamp date, or PPG receipt date, noted on the appeal or grievance request.

Information requests

PPGs, physicians and other providers – use the table below to respond to an enrollee’s request for information.

Type of request	Requirement	Time frame to respond
Receives enrollee appeal/grievance complaint	Forward to Health Net A&G Department.	Within one calendar day of receipt.
Responses to routine appeals/grievances	Submit a written response, reason for the denial and all medical records to the A&G Department.	Commercial plans: Within 5 calendar days of receipt. Medi-Cal: Within 5 working days of receipt.
Responses to expedited appeals/grievances	Submit a written response, reason for the denial and all medical records to the A&G Department.	Same day, or date indicated on the request.

Acknowledgement and resolution letter time frames

Once an appeal or grievance is received, it is assigned a case number, researched and a decision is made.

Use the table below for the time frames to provide an acknowledgement and a resolution letter to the enrollee.

Type of request	Acknowledgement letter	Resolution letter
HMO/PPO, Medi-Cal A&G Regulated by DMHC or DHCS1	Five calendar days.	Expedited: 72 hours. Standard: 30 calendar days.
PPO/EPO A&G Regulated by CDI2	No acknowledgement needed.	Expedited: 72 hours. Standard pre-service appeal: 30 calendar days. Standard post-service appeal: ­ 15 calendar days (claims related); ­ 30 calendar days (for all other appeals). Standard grievance: 30 calendar days.

¹DMHC – California Department of Managed Health Care or DHCS – Department of Health Care Services.

²CDI – California Department of Insurance.

Respond timely to information requests

The PPG, physician or other provider’s written response to Health Net A&G Department’s request for information must address each of the enrollee’s issues. Medical records may accompany, but do not replace, this written response.

• Provider Information Request (PIR) form is sent by the A&G Department notifying the PPG, physician or other provider that an enrollee complaint has been received.
• PPGs, physicians and other providers must respond by sending applicable documentation by the date indicated on the PIR. Use the contact information on the form when responding to a PIR.
• All information must be complete and accurate.

Failure to respond timely

Providers who fail to respond within the indicated time frames may violate relevant portions of their Provider Participation Agreement (PPA), including Health and Safety Code section 1374.31(a), rules 1300.74.30(j) and 1300.74.30(k).

Failure to provide timely records can result in fines and penalties assessed against Health Net, PPGs and physicians or other participating providers.  

Questions?

If you receive an enrollee appeal or grievance in error, please fax the information to Member A&G as soon as possible at 877-831-6019.

If the information is too large to fax, please mail to:

Member A&G
P.O. Box 10348,
Van Nuys, CA 91410

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.